According to the Community and Hospital Infection Control
Association (2009), infection prevention and control must be made up of
evidence-based knowledge, and up-to-date skills and implementation practices. In
their Infection Prevention Online Course (see website below), they present a
series of modules designed in such a manner that all members of the health care
team (both professionals and non-professionals) can use to enhance their
knowledge in a range of areas in order to “strengthen infection prevention
practices even in low-resource settings” (http://meds.queensu.ca/cpd/che/online_courses/infection_control)
The purpose of our paper is to help expand their educational efforts by
addressing the importance of hand washing in relation to patient safety. Nurses
are present in all health care settings and can play a key role in modeling and
promoting evidenced- based infection control practices which will ensure the
continuation of quality care for patients.

Infection Control: Can Nurses improve Hand Hygiene PRACTICES?

Hospital acquired infections have generated a great deal of
concern across North America and globally pose a significant threat to
population health (Fauci, 2006). The World Health Organization (2009) has
recently announced that the HINI influenza is nearing pandemic status. Patient
safety is of primary importance to nurses who are present 24 hours a day, 7 days
a week in all healthcare settings. Yet the safety of patients is being
compromised every day simply by being present in a healthcare setting. According
to the Center for Disease Control and Infection CDC (2002), in American
hospitals alone, hospital-acquired infections account for an estimated 1.7
million infections and 99,000 associated deaths each year. The startling reality
is that studies have shown that most hospital acquired pathogens are transmitted
from patient to patient via the hands of healthcare workers (Larsen, 1988).
Nurses have hands-on daily contact with their patients and therefore play a
vital role in patient safety and infection control. The CDC explains how hand
washing is the single most effective way to prevent the spread of infection.

The authors of this paper will highlight the historical
roots of nursing involvement in infection control and how it has influenced
their practice today. Hand washing, the one specific aspect of infection control
that needs improvement, will be explored. The authors will identify ways in
which education and pro-active intervention can increase compliance among nurses
and healthcare workers and thereby promote quality of care for the patient.

The relationship between
nursing and infection control was first identified by Florence Nightingale in
1854, during the Crimean war, when she served in a military hospital in Scutari,
Italy (Kamisky, 2004). The conditions in the hospital were deplorable.
Nightingale’s observations in Scutari led her to believe that improving hygienic
conditions would decrease the number of deaths. Kamisky (2004) believed that
Nightingale, “championed the cause of improved hygiene, food, and living
conditions for the hospitalized soldiers… she attacked the hospital conditions
and called for basic public health, infection control measures, cleanliness,
hygiene and education about the importance of the issue” (p.1 ). Jean Lawrence,
chairperson of the Infection Control Nurses Association (ICNA) believed that
Florence Nightingale was probably the first infection control nurse without
actually realizing it (Elliott, 2004). Today, nurses are key players in the
fight to ensure the survival of infection control practices.

Salient tactics to promote effective infection control
practices in hospitals

While not all hospital-acquired infections can be
prevented, the vast majority of them can. The chain of transmission of
microorganisms consists of three elements: a source of infecting microorganisms,
a susceptible host, and a transmission of the microorganism (Canadian Committee
on Antibiotic Resistance, 2007). The most basic strategy for prevention of
infection is something that most of us learn when we are small children: hand
hygiene. Despite the well established relationship between hand washing and
infection, numerous studies have indicated that hand washing among all types of
healthcare workers is poor (Harris, 2000). Ministry of Health and Long Term Care
(2002) believes that correct hand washing is the simple most effective way to
prevent the spread of communicable disease. In this section we will present 3
major strategies that can be used to promote effective infection control
practices in hospital: (1) Education that promotes the “why and how to”
of washing hands properly. (2) Intervention strategies to promote clean
hands in a hospital environment (3) Evaluation tools used to monitor the
practice of hand washing.

The relationship
between knowledge and power helps to employ and implement strategies to reduce
infection control and improve patient safety (WHO, 2005). Educating healthcare
workers, clients and families is a vital strategy for effective infection
control. There are a variety of educational strategies that can be used to help
promote hand washing and infection control:

·Patient admission videos can be used to teach patients and
visitors the importance of practicing hand hygiene and how it is appropriate to
ask or remind healthcare workers to practice hand hygiene as well

·Hospital infection control teams can be utilized to provide
in-services to healthcare workers regarding the importance of hand hygiene and
infection control

·Placing diagrams above sinks that outline the proper way to wash
hands with soap and water and the proper use of hand sanitizers can be helpful

·Instructional hand washing videos can be played on televisions in
hospital lounges and waiting rooms

Intervention strategy

Healthcare workers and caregivers often fail to comply with
hand washing protocols due to inconvenient access to hand washing utilities or
shortage of time to perform this procedure. There are a variety of interventions
that can be implemented to increase compliance to hand hygiene and ensure that
hands and frequently handled equipment remain as clean as possible in the
hospital.

Alcohol based hand rubs with no-touch dispensers
should be available in every patient room, outside elevators, in waiting
rooms and at staff workstations. The Hand Hygiene Resource Centre at
www.handhygiene.org found that
when hand sanitizers were placed next to patient’s bed that healthcare
workers cleaned their hands significantly more

Automatic sinks should be placed close to the exit of
each room. This will increase the likelihood of staff washing their hands
between patients

There should be a policy regarding fingernails that
are long, artificial or with chipped nail polish. These are reservoirs for
bacteria (Gilboy & Howard, 2008)

Rings also are a haven for bacteria. Policies need to
be commenced and enforced on the wearing of rings

Staff should be encouraged to wipe their frequently
handled stethoscopes between patients and should be discouraged from using
cloth covers on their stethoscopes

Equipment that is handled and used by healthcare
workers between patients should be cleaned regularly. Gilboy and Howard
described the importance of cleaning equipment in the 2008 article,
Compliance with Hand Hygiene Guidelines, “cleaning practices for any
medical equipment need to be followed 100% of the time” (p.197)

Opportunities to use surveillance activities as strategies
to evaluate the effectiveness of hand washing are important and instrumental in
evaluating infection control measures. The following are a few examples of
evaluation tools:

·Spot checks of hand hygiene compliance can be done with a product
called Glo- Germ (www.glo.germ.com) (Gilboy
& Howard, 2008). This product demonstrates how well one washes their hands by
using a special lamp that shows if something is left on the hands

·A 24 hour observational study of hand washing in a hospital
setting during a regular shift can be used to monitor whether hand washing
occurred before contact with the patient and following contact with the patient.
Posting these results can provide the necessary feedback to the workers to raise
their awareness

·A survey of hand washing techniques could include questions such
as: (1) How many times do you wash your hands during a shift? (2) How much time
do you spend washing your hands each time they are washed? (3) Do you wash your
hands with soap each time? (4) Do you wash your hands between each patient? (5)
Do you wash your hands after working with a patient with a cough? (6) Do you
wash your hands before changing a dressing?

Hospital acquired infections are
a threat to population health and are not going away any time soon. Due to
frequent contact between health care workers and patients, pathogens can be
transmitted from one patient to another if good quality hand hygiene is not
maintained. It is the responsibility of health care workers to keep the patients
in their care safe by modeling effective and frequent hand washing practices. A
national update from Nurse.com (2009) states that one of the actions needed by
nurses to manage HINI flu is frequent hand washing. Nurses need to have a
proactive voice in the promotion of current best practices for hand washing
hygiene. The Journal of Hospital infection (2001) explains how multifaceted
approaches including a combination of education, written material,
intervention, reminders and continued performance feedback , can have an
important effect on hand washing compliance and rates of hospital-acquired
infection. Nurses can take a leadership role in all healthcare settings to
foster an organizational culture that promotes and reflects a strong obligation
to patient safety through effective hand washing.

The authors wish to thank the faculty involved in the
Nursing 411: Nursing Scholarship distance course at the University of Calgary,
notably the Course Coordinator and Course Professor, Dr Carole-Lynne Le Navenec
(cllenave@ucalgary.ca), who offered us
tremendous support and encouragement.